70 year old male with AKI

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 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

NAME:- G VISHAL

ROLL NO :- 50

70 year old male patient farmer by occupational resident of nalgonda is bought to casuality with the cheif complaints of abdominal distension ass with abdominal pain since 20 days

Fever since 20 days

Facial puffiness since 20 days 

Breathlessness since 20 days

History of present illness:- patient was apparently asymptomatic 40 days back then he started having alcohol (360ml 4times a day)and associated with decreased food intake and after 20days he complains of abdominal distension which is insidious in onset gradually progressive which is associated with abdominal pain and pain increases with food intake and spontaneously reduces after some time.

Fever since 20says associated with chills and rigor relieved on taking medication and is not associated with cold, cough burning micturation.

Facial puffiness since 20days .

Breathlessness since 20days(gradeII to grade III mmrc) no seasonal and diurnal variation.

No complains of burning micturation constipation decreased urinary output.

Past History:

Not a k/c/o HTN/DM/EPILEPSY/TB.

History of similar complaints in the past and hospitalised for 4days

Personal History:

Appetite- Lost

Diet- mixed

Sleep - adequate

Addictions -  alcohol started at the age of 20years .stopped 3 years ago and again resumed 40days back.

Smoking started at the age of 18years stopped 3years.

General Examination:

Patient is c/c/c

No pallor,icterus,cyanosis,clubbing,lymphandenopathy,pedal edema.






Vitals:

Temp - 99.8 F

PR-112bpm

RR-24cpm

BP-130/60mmhg

SPO2-98% on RA

Systemic examination :-

Rs:- BAE+ NVBS 

P/A :- tenderness present in right hypochondrium and right hypogastric regions 

Cvs :- s1 s2 heard 

Cns :- NFND 

INVESTIGATIONS:- 








2D ECHO


CHEST XRAY PA VIEW 


ECG:- 

Usg abdomen :- 




REFERALS :- 
Surgery referal was taken i/v/o pain andomen and they advised to review usg abdomen


Provisonal diagnosis :- 

PYREXIA UNDER EVALUATION 

PRE RENAL AKI 

PAIN ANDOMEN UNDER EVALUATION 

RX :- 

1 IV FLUIDS NS @100ml/hr

2 INJ NEOMOL 1gm/iv( if temp >101)

3 INJ THIAMINE 1amp in 100ml Ns IV/BD

4 INJ MONOCEF 1gm IV/BD

5 STRICT I/O CHARTING 





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